Department of Pharmacy Practice, College of Pharmacy (Drs. Posen, Keller, Elmes, and Jarrett) and Department of Academic Internal Medicine (Dr. Messmer) and Department of Family and Community Medicine (Drs. Gastala and Neeb), College of Medicine, University of Illinois Chicago jarrett8@uic.edu
Drs. Posen, Keller, Elmes, Messmer, Gastala, and Neeb reported no potential conflict of interest relevant to this article. Dr. Jarrett is a consultant to Trevena, developer of an investigative agent, TRV734, for medication-assisted treatment of opioid use disorder. She receives research funding from the US Health Resources and Services Administration; the Illinois Department of Human Services; the Substance Abuse and Mental Health Services Administration of the US Department of Health and Human Services; the Gordon and Betty Moore Foundation; and the Coleman Foundation.
Regardless of the strategy for dosing buprenorphine, it’s critical that patients be educated on how to initiate treatment outside a clinical setting, such as at home, where they occupy a familiar haven during a potentially uncomfortable time and can be as effective at initiation as they would be in a clinical setting, with no difference in precipitation of adverse effects.
At-home induction might be more appropriate for patients who are not yet in significant enough withdrawal while in the physician's office.27 Guidance should be provided on dosing instructions, self-assessment of withdrawal symptoms, and, if applicable, patience with the slow-dissolving sublingual tablet or film formulation.
Naltrexone
Background. Naltrexone is available as an oral tablet and an extended-release, once-monthly intramuscular injection; the latter has demonstrated superiority in MAR.28 Oral naltrexone has limited supporting evidence, is inferior to other MOUD options, and should not be used to treat OUD.7 Altogether, approval of naltrexone for OUD is controversial, due to potentially unethical trials and approval processes,29 although a multicenter randomized controlled trial demonstrated the drug’s noninferiority with respect to treatment retention relative to buprenorphine.30 Used over time, naltrexone does not relieve withdrawal symptoms but can reduce cravings.
Clinical considerations. There are numerous clinical barriers that limit the use of naltrexone.
First, patients should be abstinent from opioids for 7 to 14 days prior to starting therapy; usually, this means undergoing medically supervised withdrawal in a controlled environment. This is an obvious limitation for patients who are constrained financially—those who lack, or have inadequate, health insurance or are unable to be away from their job for an extended time.
